Provider Demographics
NPI:1265734636
Name:RIVER FOUNTAINS OF LODI
Entity type:Organization
Organization Name:RIVER FOUNTAINS OF LODI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CIMINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-704-6275
Mailing Address - Street 1:7501 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-3059
Mailing Address - Country:US
Mailing Address - Phone:916-486-9639
Mailing Address - Fax:916-486-9675
Practice Address - Street 1:311 W TURNER RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-0517
Practice Address - Country:US
Practice Address - Phone:209-334-3763
Practice Address - Fax:209-334-1173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIMINOCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397004012310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility